Job Satisfaction,Intent To Stay,and Recommended Job Improvements: The Palliative Nursing Assistant Speaks

Introduction

Although there have been numerous studies assessing the job satisfaction of nursing assistants (NAs) in nursing homes and one major national survey of home health and hospice aides, there are few studies specifically focused on the job satisfaction of hospice and palliative NAs. In 2011, with funding from the Hospice and Palliative Nurses Foundation, 876 hospice and palliative NAs from across the United States were surveyed to assess their job satisfaction using the Better Jobs Better Care Survey of Direct Care Workers. ¹ The goal of the study described herein was to ascertain factors contributing to NAs' job satisfaction and intent to remain with their current employer, garner suggestions for improving NA jobs, and inform hospice and palliative care providers concerned about retaining qualified, satisfied NAs.

The role of the NA is integral to the provision of quality hospice and palliative care. These team members provide the majority of “hands-on” patient care and are often the first providers to observe and identify significant physical, psychosocial, and spiritual issues. Their ongoing relationships with patients, families, and team members and the provision of top-quality personal care are often critical components of care plan success.

Yet, NAs often subsist on low wages, receive limited fringe benefits, carry heavy workloads that are physically challenging, are offered little opportunity for advancement, ² and may feel “personally and professionally dismissed.” ³ A 2011 national study of home health and hospice aides found that their average hourly wage was $10.88, and two-thirds of the 160,700 aides surveyed had annual family incomes of less than $40,000. ² Although most NAs earn above the United States minimum wage of $7.25 per hour, the earnings of NAs working full time and providing for several children or other family members could easily fall below the poverty level according to the Federal Poverty Guidelines. ⁴ Although extrinsic factors such as wages, benefits, policies, and workload have proven to be important to NAs, intrinsic rewards (those matters related to worker self-actualization and sense of accomplishment) have also been shown to affect job satisfaction among NAs. ⁵ Not surprisingly, high job satisfaction has been shown to correlate with lower intention to leave. ⁶ Job dissatisfaction results in high employee turnover and negatively impacts organizational effectiveness, morale, productivity, and patient satisfaction. ⁷ Unhappy employees who stay on the job may exhibit poor work performance and can undermine the efforts of other employees. ⁸

Attraction and retention of qualified, committed NAs should be a top priority for all palliative and hospice provider organizations wishing to provide the highest quality of care to patients and families and minimize the costs and burden of turnover. Therefore, research specific to the satisfaction and intent to stay of hospice and palliative NAs is of value to employers and colleagues of these team members.

Methods

Prior to the initiation of any research activities, the study plan and all related processes were reviewed and approved by the Human Subjects Protection Program of the University of Louisville. A nonexperimental, cross-sectional survey design was used to collect data from a broad sample of NAs employed in hospice and palliative care settings between December 2010 and May 2011. Potential participants were invited to participate via multiple modalities—letters of invitation sent to mailing lists of nursing assistant members of the Hospice and Palliative Nurses Association and the National Hospice and Palliative Care Organization, e-mail invitations, organizational newsletters, and letters sent to employers. Organizational members of the Population-based Palliative Care Research Network (PoPCRN), a national consortium of hospices involved in multi-site research projects, were also asked to invite their employed NAs to complete the survey instruments.

Results

As seen in Table 1, on average, NAs in the quantitative analysis were middle-aged (43.7 years old), made a low hourly wage ($13.10/hour), and had both been an NA and been with their current employer more than 5 years. Respondents were from 32 different states and 192 different organizations; 98% of these were hospice programs. When asked where they provided patient care, 65% reported seeing patients in their homes, 61% in long-term care or nursing homes, 28 % in hospitals, and 27% in hospice or palliative care facilities.

Most NAs were satisfied with their job (n=603, 96.4%), were not at all likely to leave their job in the next 12 months (n=521, 83.9%), were not thinking of quitting (n=618, 98.7%), viewed their job as long term (n=497, 80.0%), would recommend their place of employment to family for care (n=614, 98.1%), would recommend their place for employment (n=590, 91.1%), received health insurance (n=454, 73.3%), were female (n=595, 95.8%), had at least a high school diploma (n=614, 98.1%), and were white (n=399, 66.7%). Descriptive demographic data were structured by the survey instrument and did not permit collection of other information such as immigration status or previous employment history. Few NAs viewed their job as short term (n=124, 20.0%), had employers who exhibited extraordinary efforts toward promoting their satisfaction (n=250, 40.5%), and had been discriminated against due to ethnicity (n=51, 8.1%).

As seen in Table 2, NAs in this sample had predominantly positive perceptions of their work environment. Higher average scores were evident in positive categories such as self-efficacy, helping others, job challenge, job rewards, and having decision authority, whereas lower scores were related to negative job factors such as feeling job was a dead end, exposure to hazards, experiencing job problems, work overload, and discrimination at work.

As seen in Table 3, the only significant predictors of job satisfaction were team spirit-rewards (OR=2.630, 95% CI 1.169–5.919, p=0.019), quality of supervision (OR=13.390, 95% CI 1.309–136.971, p=0.029), and job problems (OR=0.012, 95% CI 0.001–0.182, p=0.001). Within the job problems subscale, factors cited as the most major problems were no support from supervisor, little chance for promotions, not having help when needed, and getting hurt.

As seen in Table 4, the only significant predictors of viewing their job as long term were pride (OR=2.513, 95% CI 1.021–6.173, p=0.045), quality of supervision (OR=9.042, 95% CI 2.217–36.874, p=0.002), age (OR=1.141, 95% CI 1.103–1.180, p<0.001), and intent to leave (OR=0.008, 95% CI 0.003–0.023, p<0.001).

A summary of recommendations provided by NAs when they were asked which single change would most improve their jobs is provided in Table 5. Sixteen percent of NAs indicated they were completely satisfied with their jobs in their current state and recommended no changes. The majority (84%) of respondents provided specific suggestions for enhancing their job satisfaction. Each suggestion fell into one of four broad categories: increase compensation, improve work relationships, increase staffing, and improve management systems.

More than one fourth (26%) of all respondents indicated that the most powerful change their employer could make would be to increase compensation in some fashion. This category included responses initially coded with the labels increase pay (n=165), increase benefits (n=15), and increase number of hours worked (n=15). Examples of responses labeled with these codes included “a decent raise,” “better health insurance,” and “give me full-time [hours] back.”

Slightly more respondents (30%) recommended that their supervisors create changes to improve work relationships. Specific areas cited as needing improvement were communication (n=45), teamwork (n=22), supervision (n=30), listening (n=22), appreciation (n=44), respect (n=54) and motivation/encouragement (n=9). Responses in this category included such items as “keep us aware of what is happening in the agency,” “recognize NAs as part of the team,” and “treat all NAs equally.”

Staffing shortages were the top area of concern for 9% of respondents. Although originally an individual code, improve staffing did not logically fall into any of the other established categories. Therefore, it was promoted to a broad category of its own. “Hire more help” and “schedule enough qualified, dependable personnel to cover each shift” are examples of responses that were grouped into this category.

Finally, almost one fifth (19%) of all respondents suggested that improvements in management systems would have the greatest positive impact on their jobs. The suggested improvements in this category included ensuring that equipment and supplies (n=15) were sufficient, that NAs were adequately trained (n=90), and that scheduling (n=22) was logical and consistent. Recommendations about miscellaneous work systems (n=16) (e.g., “cut down on paperwork,” “do things to make our jobs interesting”) were also included here.

Discussion

Overall job satisfaction and intent to stay in this sample of NAs were higher than previous studies of NAs working in various settings. In a study of home health aides working in hospice and home care, Bercovitz and colleagues reported an 87% satisfaction rate. ² A recent study of 2146 NAs working in nursing homes found 83% to be satisfied. ⁵ The Better Jobs Better Care demonstration project, which surveyed direct care workers employed in a variety of settings, found that 57% of respondents reported they were not likely to leave in the next year ¹² compared with 84% in the present sample. Because the average length of employment was more than 5 years in this sample, it is likely that study participants were those NAs who found meaning and purpose in their work as opposed to those who stay in such jobs only a short time.

Because the sample in this study was overwhelmingly satisfied and reported high positive scores on most variables, the only factors significantly predictive of satisfaction were team spirit-rewards, quality of supervision, and job problems (those with a lower rating of job problems being more satisfied). Pride and quality of supervision predicted viewing the job as long term as did increased age and intent to stay (however, it is obvious that older age and length of time on the job would be predictive of a long-term view). When asked what would most improve their job, almost one third of our respondents indicated improvements in work relationships, which included supervisors and fellow team members.

Multiple studies of NAs in other settings have found the quality of supervision to be a strong component of job satisfaction.^7,13,14 In the 2004 National Nursing Assistant Survey, positive assessment of the supervisor's behavior had the strongest association with intrinsic satisfaction of all variables. ⁵ Supervisors who do not offer positive feedback, do not attend to suggestions and opinions, don't respect skills and abilities, and do not treat NAs as equal team members discourage and devalue NAs. ¹⁵ The Better Jobs Better Care demonstration project found that direct care workers with positive perceptions of their supervisors were less likely to quit, ¹² and productive relationships with supervisors and coworkers has been found to be an important factor in job tenure. ¹⁶

Knowing that quality supervision is paramount to the job satisfaction and retention of NAs, it behooves organizations to evaluate the skills and practices of those supervising NAs. Supervisors need adequate training in this role as well as the ability to maintain a supportive work environment that is responsive to the opinions and feedback of NAs and respectful of their skills, abilities, and contributions to the organization. Supervisors' treatment can be viewed by the NA as representative of how the organization views the NAs as workers and people. ³

As with this study, team spirit and a sense of belonging on a team has proven to be an important factor in job satisfaction in multiple NA studies.^7,14,17–19 Inclusion of NAs in team meetings, decision-making/policy committees, staff meetings, and social activities would be practices conducive to job satisfaction and tenure of NAs. When included in attendance, it goes without saying that NAs should be encouraged to offer feedback and opinions and their contributions should be respected and supported. Interdisciplinary team care is a core tenet of palliative care and every organization providing hospice and palliative care should be a venue where inclusiveness and respect for all team members are practiced. Organizations that invest in teamwork and include NAs as essential team members will reap the rewards of having satisfied, committed NAs.

Pride in one's work was found to significantly influence the NAs' intention to stay. In a study of job satisfaction among hospice workers, DeLoach and Monroe found that 64% of the respondents defined job satisfaction as pride in the contributions made to the organization, ²⁰ dying patients, and their families. As with other palliative care employees, these NAs' intention to remain in their job was influenced by the feeling that they are contributing to an important work or cause.

In the text analysis component of the present study, the most frequent response to the question regarding changes that would improve NAs' jobs was improved work relationships, including supervision. This further supports the finding that quality of supervision predicts both overall job satisfaction and viewing the job as long term. NAs in this sample rated being heard, appreciated, respected, and encouraged over increased compensation as the change most needed to improve their job.

Yet, increased compensation was listed by 26% as the most needed job improvement. As with all wage earners, NAs view their compensation as a reflection of the value of their work and believe that low wages minimize their skills, knowledge, and experience. ³ In a study of NAs in nursing homes, Wiener and coworkers found that a one dollar increase in hourly wages was associated with 2.1 additional months of tenure. ¹⁶ Squillace and colleagues found that, among certified NAs likely to leave their jobs in the next year, one in three cited pay as a reason to leave. ²¹ The National Nursing Home Study concluded that higher wages have more impact on recruitment than on retention; once employed, workers want to feel valued in other ways. ² This finding might explain why higher wages was the second rather than first most often offered way the NAs felt their job could be improved. Regardless, hospice and palliative employers of NAs should work to increase the wages of NAs, many of whom are living at poverty levels. NAs are often the working poor and many are providing for single parent families. ⁶

There are multiple study limitations. Although every effort was made to reach NAs lacking Internet savvy or access and to allow for written responses, there is no doubt that barriers to participation existed for those NAs uncomfortable with locating and completing online instruments or those for whom English is a second language. This sample consisted almost exclusively of NAs employed by a hospice/palliative care provider, which limits generalizability of the findings to those employed in settings where such care is the focus. Employing organizations were asked to invite their NAs to participate and, in a number of cases, the employer circulated and returned these surveys; therefore, employer coercion could be a threat to study validity (although most employers submitting surveys reported efforts to maintain respondent confidentiality in the process).

Findings related to factors affecting job satisfaction are limited to the options of the structured survey instrument; there may indeed be factors specific to hospice and palliative work that contribute to job satisfaction not captured. For instance, the instrument did not address specific work factors related to daily work with seriously ill and/or dying persons and their families.

Conclusions

This study found hospice and palliative NAs to be satisfied and committed to their jobs, which most viewed as long-term careers. However, organizations committed to recruitment and retention of committed and satisfied NAs would do well to ensure high quality NA supervision, include NAs as valued team members, encourage positive work relationships, work to reduce problems identified by NAs as interfering with their work, and continue efforts to increase NA compensation.